Management of Incidental Adrenal Masses: American College of Radiology white paper

Last revised by Yuranga Weerakkody on 15 Nov 2021

The Management of Incidental Adrenal Masses revised in 2017 by the Adrenal Subcommittee of the Incidental Findings Committee of the American College of Radiology is an algorithm for the management of patients who are:

  • adults (≥18 years old)
  • asymptomatic for adrenal pathology
  • referred for imaging for reasons unrelated to adrenal pathology
  • adrenal masses <1 cm do not require further investigation
  • incidental masses should be categorized according to diagnostic imaging features, mass size, growth (cf. prior imaging if available) and cancer history
  • dedicated adrenal CT is preferred to determine if a 1-4 cm mass with density >10 HU is a benign adenoma
  • wherever possible, the stability of a lesion should be assessed with any modality that has imaged the adrenals in the past (e.g. chest CT, PET-CT, abdominal ultrasound, lumbar spine MRI)
  • consider patients’ comorbidities, life expectancy and ability to receive treatment before recommending further investigation

For an incidental, asymptomatic adrenal mass ≥1 cm.

  • myelolipoma or lipid-rich adenoma
    • macroscopic fat
    • density <10 HU on non-contrast CT
    • signal loss compared to the spleen on in-phase and opposed-phase images of a chemical-shift MRI sequence
  • cyst
  • benign calcified mass e.g. old hematoma or granulomatous infection
  • hemorrhage
  • normal or benign serum calcium
  • no follow-up required

1. prior imaging

  • stable ≥1 year and no biochemical features of functioning adenoma or pheochromocytoma
    • no follow-up
  • new or enlarging
    • no cancer history
      • consider follow-up adrenal CT or resection
    • cancer history
      • consider biopsy or PET-CT

2. no prior imaging, no cancer history

  • <2 cm
    • probably benign, consider 12 month adrenal CT
  • 2-4 cm
    • adrenal CT

3. no prior imaging, with cancer history and isolated adrenal mass

  • adrenal CT
  • with no cancer history: consider resection
  • with cancer history: consider biopsy or PET-CT
  • reduced dose non-contrast CT ≤10 HU and no biochemical features of functioning adenoma or pheochromocytoma
    • benign adenoma, no follow-up
  • non-contrast CT >10 HU
    • adrenal CT washout
      1. no enhancement (<10 HU) = cyst or hemorrhage
        • benign, no follow-up
      2. absolute percentage washout (APW) / relative percentage washout (RPW) ≥60/40%
        • and no biochemical features of hyperfunctioning adenoma or pheochromocytoma
        • benign adenoma, no follow-up
      3. APW/RPW <60/40%
        • imaging follow-up, biopsy, PET-CT or resection depending on the clinical scenario

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